Oral and maxillofacial surgery—is it time to rethink the long training pathway?BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i1148 (Published 29 February 2016) Cite this as: BMJ 2016;352:i1148
- Peter A Brennan, president1,
- Velupillai Ilankovan, consultant oral and maxillofacial surgeon2,
- James S Brown, consultant oral and maxillofacial surgeon3,
- Alex Goodson, year 3 specialty trainee in oral and maxillofacial surgery4,
- Karl Payne, year 3 specialty trainee in oral and maxillofacial surgery5,
- Arpan Tahim, year 3 specialty trainee in oral and maxillofacial surgery6,
- David A Koppel, consultant craniofacial/oral and maxillofacial surgeon7
- 1British Association of Oral and Maxillofacial Surgeons, United Kingdom
- 2Poole, UK
- 3Liverpool, UK
- 4Wales, UK
- 5Birmingham, UK
- 6London, UK
- 7Queen Elizabeth University Hospital, Glasgow, United Kingdom
Oral and maxillofacial surgery has the longest training pathway of any medical specialty in the UK. Peter Brennan and colleagues look at ways to shorten this
Oral and maxillofacial surgery is facing a critical time as demands on the specialty rise and the number of trainees is expected to fall.
Two major issues face the specialty: the length of the training pathway, and the need for the clinician to have both medical and dental degrees before they start specialist training. Oral and maxillofacial surgery began as a dental specialty but as the procedures became more complex the need for practitioners to have a medical degree became obvious. This necessity was formally recognised in 1984, and both dental and medical undergraduate qualifications as well as core surgical training were made mandatory, making the higher training programme equivalent to all other surgical disciplines.
The development of the specialty over the past 30 years has meant that much of the work involves close collaboration with other specialties, and multidisciplinary working is the norm. UK training is recognised internationally as being to the highest standard, and is often used as an exemplar of best practice.
The specialty provides an interface between dental services and hospital based medical and surgical specialties. This gives surgeons a varied, interesting, and highly rewarding career with opportunities to develop soft tissue surgery, bone surgery, and reconstructive skills.
A dental degree gives detailed knowledge of the anatomy and pathology of the oral cavity and jaws and teaches many technical skills that are not taught at medical school.
European law currently requires oral and maxillofacial surgery specialists on the medical register to hold a registerable dental qualification. The 2008 postgraduate medical education board report on training in oral and maxillofacial surgery concluded that this was mandatory.1
Interestingly, although dual qualification is needed, the requirement to be registered with both the General Medical Council (GMC) and the General Dental Council is not essential, and many consultant surgeons are registered with the GMC only.
The GMC’s small specialty review in 20142 recommended that all stakeholders should explore ways of streamlining the education and training of those doctors and dentists wishing to pursue a career in oral and maxillofacial surgery.
With the increase in undergraduate fees, the impact of pension reform, and the changes in NHS regulations pertaining to protected pay, it is likely that fewer trainees will embark on a career in the specialty.3 Graduates who have passed the entrance examination for membership of the Royal College of Surgeons can choose another surgical specialty. Those with a primary dental degree have no choice but to go on to study medicine if they wish to pursue a surgical career. Some colleagues have questioned whether a dental degree is required to practise the specialty. Others consider this to be essential, and would not wish the status quo to be changed.
What are the changes that need to be considered, and what are the challenges facing each one?
Revert back to a dental degree only specialty
This could be combined with additional specialty training to improve general medical and surgical skills and knowledge—perhaps leading to a medical diploma. This system has been used in the past, but the view was that it did not provide the safest care for patients. Any top-up medical training needed would mirror the existing shortened medical courses available to dentists now, and would not lessen training time. From a legal perspective, the specialty would cease to be oral and maxillofacial surgery and become oral surgery.
Move to a medicine only specialty
A medical degree would need to be combined with a dental diploma that taught those aspects of the degree course that were relevant to the specialty. The GMC would have to recognise formally the European Union’s definition of the specialty of maxillofacial surgery.
Incorporate the second degree within a formal training programme
This approach would not require legislative change. It would deal with the pension and pay protection issues. It would also maximise training opportunities within the training pathway, giving opportunities to shorten training. In many medical and dental courses a significant amount of time is given to student selected components, and for oral and maxillofacial surgery trainees it would offer opportunities for training while gaining a second degree. This plan would need considerable support from medical and dental schools and, considering trainee numbers would be small, their support may not be forthcoming. It may be possible for the surgical colleges to re-establish their licentiate examinations to let candidates obtain registerable degrees. The specialist advisory committee on oral and maxillofacial surgery is currently working with the University of Glasgow and the Scottish Surgical Training Board to pilot a specialty training programme that incorporates the second degree, and is awaiting the response of the GMC to this proposal.
A critical time
We believe that the specialty is facing a critical time and that in 10 to 15 years there will be a greater demand with fewer specialists. The specialty is responsible for the care of many patients with head and neck cancer (the incidence of which is rising) and virtually all facial trauma and facial deformity management. If the profession does not tackle these training issues the burden of care will fall on other specialists who will not have the necessary training.
Competing interests: None declared.